Saturday, 8 October 2016

Good Karma is a Great Investment !

Yesterday I ended working the Hurricane Shifts. 

Patients came to  the ED With clean cut non emergent complaints.

I was a little taken aback until one of them after giving a long list of complaints 
softly said - " I am afraid of the dark"

That left me thinking - the ED is definitely not a happy place to be, the ED is 
not where I would wish for anyone to be , 
it's only when someone feels that they have no one or they 
will find someone who will care for them that they turn to ED.

Patients genuinely believe they have a problem and they come to us, 
and they confidently know that we will care for them and
WILL SEE THEM whatever their complaints are.

Regulations, Legal Threats and Metrics may be ruling us but over and above all these 
challenges ..... it's is the faith of these patients which keeps our specialty going.

I also get worried when I see patients seek pain medications and they come 
for non emergent complaints .... but thinking further ... 
who created that sense of security for them ..... 
the system did and we as a physician specialty did it ! 

It is challenging that we have to face so much 
pressures in terms of patients per hour etc and still balance satisfaction scores .....
 I will say that perform and be calm in stress is not easy.

There is no one solution for what we are going through , 
but definitely there is one solution .....
 let's start thinking that we are the only ones who 
can help those who need our help and we have 
only a certain number of Of hours in which we can make a difference.

To be on the other side of the bed is not easy ..... 
when you make it easy for someone .... it does make a difference.

Good Karma is a great investment.

On another note .... 
our soldiers defend our nation and freedom no matter what it takes ...
 they are at the front lines of defense .....
we are the front lines of Health Security for our citizens 24x7 .

Our patients take it for granted that we will care for them and the EM system is solid ...
 that's a good thing !

Just Thought .... should share !

Stay Blessed ! 

Monday, 8 August 2016

It’s all about the Encounter……, but what about Metrics?

There have been waves of changes which are happening across the world of emergency care. Different nations approach emergency medical services differently.

The one thing that continues to remain common is the patients their pathologies and the metrics which govern the operations of emergency departments.

In accountable cultures the patient experience is a key feature of the emergency department visit. Physician salaries and insurance payment for clinical care are tightly tied to the satisfaction level of the patient once the care provided has been availed. It is more like an evaluation you give after you avail a Telephone customer service. There is also a lot discussion which suggests that Good Patient Experience in the Emergency Department leads to lesser complaints and lesser legal problems.

On the other hand we have the massive pressure of metrics. There are different metrics in different cultures and different nations. It’s all about the financial logistics which drive sustainability.
So the demands on the Emergency Physician are tremendous.

Let’s look at the parameters of this perspective:

Emergency Departments are getting overcrowded:
That is good for the specialty but also a reflection of the strength of primary care available. Hence when patients seek Emergency Care for primary Care pathologies….there is a strain on the system. Seeing patients fast, screening the life threatening pathologies out from the waiting room and maintaining pleasant patient experiences becomes challenged.

Emergency Department Metrics:
Metrics and Measures drive the working of a Modern Emergency Department. How many patients are seen per hour per physician, how many CT Scans are ordered, How many tests are ordered, how soon were antibiotics, aspirin and life saving measures instituted etc. These are benchmarks and may like these to which an Emergency Physician has to strictly adhere too or there may be no employment…

 Patient Experiences:
With the existence of above pressures which include seeing patients fast, evaluating them and treating them safely, and maintaining the numbers for meeting core measures and metrics the Emergency Physician is responsible for making the patient experience a satisfying encounter.
There is a lot of thrust on the above Marker. I am well aware that hospitals and health system are hiring 5 Star Hotel Hospitality Gurus to create Hospitality Training Models for health care workers.

How does one welcome the patient, how does one behave with the patient as soon as the patient car hits the gate of the hospital, till the time the patient goes home.

It’s all about Communication Skills….. That’s what it comes down too.

But what about Emergency Life threatening Conditions, Critical Life Saving decisions Scenarios, a critical environment where things change within seconds…..

Emergency Departments and Emergency Patients are different from Primary Care Patients and Clinic practices.

I firmly support that compassion is key to patient care and it’s all about communication skills BUT different things are done differently in different situations.

It’s good to be inspired from the airline industry to design a Safety checklist for healthcare and it is good to be inspired by the hospitality industry to introduce customer satisfying protocols….but in Emergency Health Care…. We have real patients…. Not Air Travelers and definitely not the crowd which visits resorts and beach hotels.

The psychological mindset is totally different on either sides… patients and providers.

We have to work on Safety norms which consider the culture of Acute Decision Sciences at the same time the Communication algorithms have to be modified into a systems approach.

Physicians have to be kind to their patients and communicate with them and also meet the metrics.

Greeting patients, updating them about the plan and also appraising them of the test results and the future course of action is key. Closing the encounter by telling the patient what you are going to do …discharge or admission and details of the process are key.

If you haven’t been able to appraise them then apologizing and then appraising them is of help…. But again this if put into a process will definitely change the way we deal with our patients.

The process needs to play a role because metrics and overcrowding are key factors and just assuming that Patient Experience is directly equal to Physician Communication Skills is not completely correct.
The whole culture of communication has to start from the time patient arrives in the ED. If the patient expresses the slightest concerns then the team member has to activate the physician of the concern and that should be addressed and documented.

Documentation is key and Communication is also visible via the documentation in the chart.
There will be patients who are tough to deal with … but again it’s all about the skills and not getting emotionally hijacked is the key.

All this needed intense training and an ongoing commitment to improve oneself. Taking the feedback on patient complaints positively and the advice of your colleagues and nurses positively is very important for personal growth as a human being.

Treat you patients like you would like to be treated……. My Teacher taught me that and I continue to practice the same !

  From the Desk of                                                                                                                                                                                         Sagar Galwankar, MBBS, DNB, FACEE (India), MPH, Dip. ABEM (USA), FRCP (UK)

Friday, 15 July 2016

PokeMon Emergencies : A Call for Public Health Safety

From the Desk Of:
Sagar Galwankar, MBBBS, DNB, FACEE (INDIA), MPH, Dip. ABEM (USA), FRCP (UK)

As I went to work I saw few of my colleagues discussing about this new app called PokeMon GO.

This is a Freely available Video Game played via a downloadable app. 

This allows players to capture digital creatures at real locations synchronized with GPS. The GPS Activated locations are called POKESPOTS and the players can capture and gain points called XP. 

There are various awards and rewards by playing this game. 

This has a lot of implications. 

There is massive Public Frenzy and craze and as I had guessed People are trespassing and many accidents and injuries are anticipated when driving walking as people continue to play  and not pay attention.

A New Era of Public Safety Threat has emerged and reached a whole new level !

I recently read this article:

Were we not glued on enough to the Smart Phone on Social Media and video games ?

Were we not disconnected enough that Messaging became the New means of Communication ?

Were we not lonely enough that animated characters are the new friends ?

Technology can with advances but also came with Public Health Threats.

Smarts Phone created a new platform and era of STAT COMMUNICATIONS and UPTODATE INFORMATION.

That brought the Public Health Threat of Civil Safety as Social Media played an Open Access Platform with information about who is doing what and when.

It also brought to light the Road Safety issues where crashes happened while Texting.

It brought to light the violation of privacy of people in the world.

I believe that Mass Frenzy is a phenomenon which has often been the single most important factor to heightened ignorance and accidents.

Travel on Roads as a Driver/ Rider or Pedestrian, Walking at Home or at work and not focusing on what you do will cause a fall/crash and injuries are more severe than ever.

I have seen patients who have got insomnia as a result of sounds and rings of social media and their addiction to see the phone a Pavlov Rat.

This Digital Plantation of Revolutions have brought a new age of humans who have isolated themselves to find solace in their single trusted friend.....their smart phone.

Video Games are the new friends introduced by this trusted friend.

There have been many news which have already started reporting injuries and accidents and I soon think we will have to ask for every car crash / and fall .....Were you playing on the SmartPhone ?

The answer may just be YES.

I think its time that Public Health Social Marketing Strategies highlight the urgency to design initiatives to break this addictive unsafe habits of SmartPhone Public Health can be safer than before !

When people's mind is fixated on one thing then that is what drives their lives. 

Texting, trespassing and all the crashes falls and accidents with the above apps proves that these are sane people who are conditioned to commit themselves to this public safety risk and hazards..... this is much bigger than just a Habit.... this is addiction and the single biggest Mental Health Challenge to Public Health.

Thursday, 7 April 2016

"For The Patients" ~ Lets talk about Headache in Adults !

From the Desk of Sagar Galwankar, MBBS, DNB, FACEE, MPH, Diplomat. ABEM, FRCP

The Patients who come seeking Emergency Care...."My Emergency Patients in My ED" is all that has mattered since years as it is because of them that I am a EM Doc and this specialty called EM exists.

I see lots of Social media Posts trying to be to become Education Materials. I see EKGs being discussed on social media. Nowadays they are the new classrooms.

So lets talk about symptoms which need lots of thinking and are High Risk.

This series will be called "For the Patients"

Today I will discuss HEADACHE.

Headache is one of the common symptoms when patients come to the ED.

Headache can be a Presenting Complaint when the patient arrives. "I got a Headache" and sometimes when patients are being evaluated at bedside for some other symptoms they can add the complaint "..and I also have an Headache"

History takes paramount importance when a patient complains of Headache as a Primary Symptoms or a Co-Symptom as a part of a Series of Complaints.

Always evaluate Headache keeping a 360 Degree approach.

Always address Headache. via your Thought process, History taking and Clinical Exam.

Vital Signs take a Lot of Importance and ask for them as you immediately prescribe pain medications to treat the PAIN.

Temperature, Pulse, Blood Pressure, Respiration, Pulse Ox, and Bedside Glucose are key stat Bedside Parameters which guide you to a story. Order an EKG Stat and read it.

Remember:  Gender does matter ! Pregnant Females & Females who do not know they are pregnant can come to the ED. Being Pregnant Changes the way you will evaluate these patients. Having abdominal pain, Hyperemesis gravidarum vaginal bleed can come with an headache and evaluating for abdominal emergencies and Ruling out Ectopic Pregnancy at the same time deciding about CT Head and Headache work up is a complex issue. They can also have HELP Syndrome or Eclampsia also can start with Headache.

Age is crucial before Young Female with Headache and Cold and Cough is different from a 50 Year old with Headache and Blurry Vision.

History taking should include: When did it start, how severe is it from a scale of 1-10, any other symptoms of Dizziness, Focal weakness, Gen weakness, Vision changes, neck pain, Syncope Seizures, Nausea, V omitting Diarrhea, Chest Pain, SOB, Neck Pain/Stiffness, Dizziness, Vertigo have to be ruled in or ruled out.

Past History of DM HTN CAD CVA Cancer HIV Hep B Hep C are important.
Is patient on anticoagulants also is key history point.

Some Cluster approaches are:
Fever, Tachycardia, Headache, Neck Pain: Here Headache can be as simple as a Viral Fever or as severe as early meningitis or even a URI if Cold Cough Sinus Tenderness are present.

Headache could be a early Bleed (Subarachanoid) or even a CVA when patients have vasculitis, Bleeding disorders, Hypertension , DM.

Headache can be due to Glaucoma or due to Otitis Media or even early Temporal arteritis.
Headache can be segmental along a nerve for a early developing Zoster.

Syncope, Fall, Seizure, Loss of Sensorium, Altered Mental Status with Headache all can be indicating a worse diagnosis  than how the Headache presented.

Post Ictal Phase can present as Headache.

Another con-founder: MI/ACS can also present as an Headache so can arrhythmia or PE. So EKG Trop are Important.

There have been cases who have presented as an Headache and when you do labs there has been Low Hemoglobin and patient has a GI Bleed and the Immediate anemia has caused an headache.

Be very particular and alert when Patients says "Headache is what brought me to the ED"
On the other hand there is tons of Literature of approach to Migraine in ED.

Its very important that you read the literature as there are various combinations of medications used to break the migraine.

When a patient says "I have a Migraine attack" you still have to approach it as an HEADACHE.

Sometimes patients present with Neck Pain and Stiffness and we disregard it as "Slept on wrong side or Neck sprain". Evaluating for Cord Compression and keeping Dissection and SAH as a differential is equally important as much as ACS/MI or even a Retro pharyngeal abscess in a URI patient.

What it comes down to is:

Vitals, Past History, Med List, Clinical Co-Symptoms, History of Complaint, Detail Clinical Exam to include total undressing of patient Neuro Vascular HFN HEENT Exam and Lab Results is crucial.

Overdose and Drug abuse are important historical points which can indicate Cocaine abuse or even overdose unintentionally on paracetamol ibuprofen trying to self medicate with Over Counter Medications.

CBC, LFT RFT Trop EKG UA Tox Screen and CT / MRI ESR are a part of the work up in ED.
In a patients with Hypoglycemia or Hyperglycemia Ketoacidosis versus Toxicity v/s sepsis or infection has to be kept at back of mind.

In HTN emergency headache can be because of raised BP and Raised BP can cause headache. Treating both is important but also is important ruling out cardiac pathologies a CT Head and look for Posterior Reversible Encephalopathy Syndrome.

I have also read reports where patients were on anticoagulants and had neck pain and when MRI was done it has Hemomyelia into the spinal cord.

There have been cases alcoholism where patients wake up with headache in ED but they dont know that Methanol or Toxic alcohols were also drunk and they have an Headache.

Being very aggressive to rule out meningitis and SAH and using Spinal Taps with Clinical Co relation is important in the ED.

Patients often return post spinal tap with headache and at this time Blood Patch becomes a choice after you have ruled out any other cause or pathology.

Patients also have headache after Nitro given for Chest Pain.

Fever can exacerbate Headache and Hunger can do that too.

A TIA can be presenting as Headache being one of the Co-Symptoms.


Always Document in detail the history the clinical exam and the plan for ordering tests and meds and chart your thought process and notes as you reevaluate the patient.

That helps and maintains the continuum of care at the same time maintaining standards of care.
Discharge is a crucial part. Here too Educating the patient and giving return instructions is key.

Do not Disregard or Less regard HEADACHE. Its a Part of the PAIN PATHOLOGIES which can cause PAIN if ignored.

Patients have Pain , treat it first but work it up and decipher the cause then treat the cause....  FOR THE PATIENTS !

Saturday, 24 October 2015

The Prime Focus on Health: Questioning Actions, Charting Challenges and Demanding an Answer ~ Is the answer - Voice, Visibility or Ability?

From the Desk of Bipin Batra, MBBS, DNB ~CEO & Executive Director NBE & Sagar Galwankar, MBBS, DNB~CEO of INDUSEM

The Social Media and Print Media are all buzzing with some Editorial Article in a Journal questioning the Governance in India as regards the health care policy.
India is being subjected to a Media Trial with serious questions being raised about its Health Policy actions and alarming deductions predicting India’s Health Care doom as against the predicted Health Care Boom by the whole investment world.

Let’s look at some of the actions in the Health Policy, Public Health and Global Diplomacy arena with respect to India.
I answer because India is in Question:

India is openly committed to a People Centered Health Model with simultaneous and equal investments in Research, Education, Treatment, Public Health and Global Health with a progressive vision.

The massive expansion of the Translational Research Program lead by Department of Biotechnology (DBT) with focus on finding solutions to diseases at a Nano-Molecular level will make India as a Biotech Leader in Asia.

The installation of Progressive and Aggressive Leadership at the Helm of Indian Council of Medical Research (ICMR) and DBT reinforces the commitment of the Government to solve the TB / Communicable and Non Communicable Disease Crisis.

The Directors and Secretaries at both above departments bring years of successful program development and implementation at their earlier positions. Their experience and capabilities can now be escalated at National and International Level.
ICMR and DBT are developing Live Surveillance and Study Systems at Molecular, Genetic and Patient Care Levels at multiple locations to gather data and act on the findings to derive fast track solutions.
Increasing funding and encouraging research at Medical Students, Teaching Faculty and Private Hospital Level is a Major area of Expansion for ICMR and DBT.


Increasing the number of seats across Medical Colleges, Spear Heading the creation of AYUSH Ministry and focusing on the growth of Traditional Medicine as well as increasing number of Allopathic Graduates is a major game changing strategy by the government.
Reformatting the Medical Council of India (MCI) and bringing in intense coordination between the National Board of Examinations and MCI to bridge the difference in number of Under Graduate Medicine Seats and Post Graduate Medicine Seats will be a major accomplishment whose results will be robustly visible in coming years.

The biggest feather in the cap is the National Roll out of the Specialty Training Programs in Emergency Medicine across NBE Recognized and MCI Recognized Hospitals across India. The First Programs started in the Home State of PMO when he was CM of Gujarat and today they are across the Nation.
Until 72 Hours ago commitments were made to develop More AIIIMS and Similar Institutions across States in India with a vision that every state will have an Apex Institution for Super Specialty and Complex Health Problems.

Building on the earlier vision to develop Trauma Centers in India there was no Training on Trauma Surgery in India and now the Government with the help of the Academic Community has rolled out Subspecialty training in Trauma Surgery and Critical Care.

Additionally Post Graduate Training in Family Medicine has been a Prime Focus to create Specialist Primary Care Doctors across India.


We must admit that India is the Epicenter of Economical Generic Medication Manufacturing and Global Supply of the same.

Development of National Treatment Algorithms for DM, HTN and HIV, TB and Malaria as well as Faster Diagnostic Technologies and infrastructure development for rare and common diseases are the prime agenda of Indian’s Health Security.
As a part of India’s Commitment to the Global Health Security Mission, India in partnership with WHO, UN and USA Governments is implementing various multi-level strategy to address Prevention, Diagnosis, Response and Policy of Major Infectious Disease Threats and Challenges.

As a part of the Quality and Patient Safety Mission the NABH and NBE have formalized a Maiden Partnership to augment dual certification for Quality and Educational Accreditation. This has started with Accreditation EM Departments for PG Training as well as for Patient Safety and Quality Care. This will be expanded to the whole facilities and soon all the Educations Institutions will follow.


Rural Health Care:
Efforts are on and strategies are being made to use the Rural Health System as a training and education gateway by creating Post Graduate Training Programs at Rural Health Centers with National Procedural Skill Training Centers for Specialty and Sub Specialty HealthCare at Major Institutes in Every State of the Country.
Private-Public Sector partnerships to Operate Primary Health Care Centers and incorporating Ambulatory / Mobile Health Care Delivery Models are also being developed across major States.

Multi-Level-Multi-Fork Strategy:

Involving Private Hospitals, Governmental Hospitals, and Hospitals under NABH, NBE, MCI and Health Facilities under the purview of Directorate of Health Services of States, Interacting with National and International Health Agencies, Working closely with Bio-Pharma Industry and Commercialization of Innovation with a focus on India’s Health Security is the Interlaced Model the Government is working on.

Various Acts/ Policies and Laws are being Modified, Amended and being worked on as India moves ahead with its Progressive Health Agenda.
The Existing PNDCT act is being fortified to crack down on Female Feticide with greater vigilance being instituted. Additionally experts group are working on amendments to validate the use of Ultrasound in Emergency and Trauma under the purview of the PNDCT Act.

Experts are working on putting together the Bhartiya Emergency Medicine for All Act (BHEMAA) which will be a Historical Move to ensure Emergency Care to every citizen of India.

The Clinical Establishment Act is being implemented with great care and will show results in coming years.

Funds are bring allotted and States are being encouraged to ensure Ambulance Services for all Emergency patients. This is a step towards having an EMS Service for the whole nation.

A universal Emergency Number is also being issued.

International Investments are flowing into states with Uttar Pradesh Being the First State to have Massive Foreign Direct Investment in HealthCare in year 2014. This is called the SVADESH Program lead by Investors from Silicon Valley, USA.

The government is not basking on its success of a Healthy Kumbh Mela at Nashik or the eradication or polio or its Disaster Response system which not only is successful in India but also helped neighbors during environmental crisis, instead it is moving ahead with changes which are progressive.

The Health Care Models in Gujarat are complimented by similar models in Rajasthan Chhattisgarh and Many States.

Flagship Projects:

The Swach Bharat Abhiyan is a massive SEffort for Public Health &Cultural Transformation where efforts are being made to establish civil sense and responsibility.
The same applies to organ donation, and various other programs where massive media marketing is being used to instill Championed Cause for various initiatives.


There are endless such initiatives which can be listed.

The Government is focused on building relations with Nations to speed the Economy. Health is a Silent but Vibrant Part of this Wealth Story which will not only progress India but also Position it as a Stable Player in Peace and Security.
India has a population of 125 Crores and hence problems are many. Governmental Health Care is available for all but Utilized more than 70 %. Rest use Fee Based Corporate Care.

Just because Health has not been in the news does not mean India's Health Story is doomed.
The results of Health Interventions in the Populations take time to be visible.

I still am open to specifics as we continue to be critical of the definition of Visibility, Voice and Viability as well as question the sheer existence of Ability.

I think Remembering Sustainability is equally important!

Saturday, 9 May 2015

INJURED FIRST !!! : Road Traffic Trauma and the Complexities of being a Good Samaritan or a Responsible Driver in Developing India

Prevention is better than being a Patient

From the Desk of Sagar Galwankar, MD, FACEE, Diplomat. ABEM (USA)
Amongst all the media discussion about the court verdict in a recent celebrity hit and run road traffic case I found myself thinking about the complexities of this whole issue of road traffic injuries in India.

India is changing and it’s happening fast. International Cars are now being driven on Indian roads. These are high speed cars. India has now gotten expressways which are four lane to six lane. Heavy Motor Vehicle Travel has also increased with economic growth and manufacturing industries making India their home.

People can now own vehicles with ease, thanks to loans by prospering banks.

In all this frenzy one thing hasn’t changed and that is the behavior of the Indian Road Traveler.

The Road Safety Education and the Road Travel Skills still continue to lag behind.

Drivers love to have cars which can easily speed 120 km/Hrs. without realizing that if the tires burst then death is instantaneous.

I often wondered why there are speed limits on roads and after much research found out that the speed limit is calculated based on the probability whether an accident at that speed can enhance least damage and survival. It also takes into account pedestrian traffic and volume of traffic. So in all abusing the speed limit is high risk by itself.

Drinking alcohol and driving is a big No and the highest risk because in a crash the first to die could be the driver itself.

Now in case of two wheelers the concept that the rider should only need a helmet and the back seat rider doesn’t need one is something which is very difficult to comprehend by me. In a crash both the riders will be equally exposed so without a helmet the rider is at high risk of death.

 I was travelling in India recently and in a city I saw a crash happen in front of my eyes. A driver was driving his imported car and it crashed into a motor cycle being driven by a Non Helmeted rider. It was an accident because the motor cycle skid and came in front of the car and the rider got head injury. The rider was awake and bleeding but what happened next ?

People gathered and started beating up the driver who had stopped, gotten out of the car and picked the rider and put him in his car and was taking him to the hospital. The first response of the by standers was the Driver in Car must have made the mistake …… Hammer the driver.

This is a wrong behavior which needs to be changed. The thought that Car Drivers have more money so they can afford cars and if they are in a crash it’s their fault so take justice into their hands and forget the patient is absolutely wrong. Forgetting the patient is just wrong.

This leads to the phenomenon of drivers running away after hitting other pedestrians / vehicles. If anyone wants to take the crash victims to the hospital they will not and just run away because they don’t want to face the mob mentality.

On the other hand drivers should be responsible whether on bikes or in car to maintain slow speed and make sure they don’t hit anyone.

 Wearing helmets, driving with car seats for children when with children , driving within speed limits, wearing seat belts, checking their eyes, not driving if they have high diabetes or seizures or pacemakers are some of the responsibilities Citizens have to exercise on their own.

In many of my public events where I was called to inaugurate Road Safety and Basic Emergency Care Training programs I ask one question: What do you do when you see a crash on the road?

The truthful answer I get is: we don’t stop because we don’t want to get involved with the Mob or the Police.

Why are we as citizens afraid of doing the right thing?

Police will not bother you if you helped a bleeding victim. There is no use of learning Basic Life support courses if you don’t have the intent to help someone in need. We still are far from having EMS within minutes so the cars and bystanders are the first responders and hence going to a hospital which has 24/7 Emergency Care with Radiology and Laboratory Back up is the first important step after stabilizing the airway c spine and stopping the bleeding.

Focusing on the Injured is very important and that’s a First.

We have crowded cities and vast rural corridors.

We have lack of space for pedestrians to walk that’s why they walk on roads.

We have high speed corridors going through rural area without crossings, overhead bridges or barricades.

This is all there because development and infrastructure are in a mismatch.

What we can match is our behavior.

The vehicle industry and the road traffic license departments have to take a lead role in education and regulation of behavior of travelers. Just selling vehicles and issuing licenses is not the only responsibility.

Changing our behavior and educating the masses that a crash is a crash and INJURED FIRST should be the focus is the responsibility of the Social Media, Marketing and Medical Community.

Avoiding a Crash is better than being in one….still crashes will happen.

We should be responsible and always remember the INJURED IS ALWAYS FIRST !

INDUSEM has launched the Jan Suraksha Abhiyan on Injury Prevention which compliments the Prime Ministers Jan Suraksha Bima Yojana on Insurance of Accidents and Injured victim.

Thanks to Web Images for the open source Picture !

Saturday, 4 April 2015

Come April - Rules For Fools: Do they help ?

From the Desk of Sagar Galwankar, MD

I realized its April when the Social Media was buzzing with Jokes ridiculing Fools and Celebrating Happy Fools Day.

As celebrations and rediculations continued across the world needy patients continued to visit Emergency Departments and continued to be cared for as I sat wondering “When we come to Things like “Standard Orders”, “Protocols” Can we make Rules for Fools?

There is a lot of discussion that Emergency Medicine is all protocol based, its overkill of investigations, it’s all to the point, etc. etc. Additionally when it comes to Education, I come across many strategies in EM Teaching where educators want to shorten lectures and topics making the lectures “To the Point” without going into the deep logic.

Yes, Emergency Medicine is based on Fundamentals of Unknown and Vital Signs govern the paths to diagnosis and care, but I  vehemently maintain that Emergency Medicine is a science, it does have an immense content of basic medical sciences and the algorithms are based on scientific evidence with a deep understanding of the way the nature of pathology works.

Emergency Medicine evolved from a Traffic Police System of Symptom based stratification and stat disposition to different departments & physicians to its current day where one Expert called as THE EMERGENCY PHYSICIAN mans the Emergency Department with his knowledge, skills, Diligence, and intelligence. This EP makes the lives of his colleagues from all disciplines who work on the floors and wards easier thus providing Urgent Clinical Care by a Specialist to the Emergency Patient immediately on arrival to the hospital.

This transition has brought immense value to health care.

I remember the time when single handedly I started the mission to develop Emergency Medicine in India and was ridiculed by the all physicians from different specialties and hospitals.
Today the same hospitals are selling Emergency Medicine as their strong points and advertise claiming the best emergency care just to attract more patients.

Coming back to the point:

Standard Orders, Protocols and Clinical Pathways are basically a set of rules which have to mandatorily be followed. 

The creation of such templates comes after a lot of discussion, debate and consensus both at a scientific level and then at an operational level in an individual facility.
The philosophy behind such Pathways is to make sure that every patient is cared for matching the clinical evidence available. These pathways also envision ensuring that the slightest risk is negated and every patient is safely cared for.

Well the most common and the most famous clinical pathways are for Chest Pain / Acute Coronary Syndromes/ Stroke / Sepsis while the Resuscitation Pathways are standardized for Cardiac Arrest and Trauma for both adults and children. 

Clinical Protocols is a different league wherein every facility has its own Standard Set of orders to overcome the Challenge of Overcrowding and underdiagnoses / misdiagnosis of life threatening conditions. Not Missing AMI / Stroke / Sepsis or any life threatening condition, and hastening diagnosis by kick starting investigations and administering fluids, pain meds, antibiotics, antiemetics and antiallergic medications etc is the intent of such orders.

The complete spectrum of this approach is to make sure patients are cared for safely and are offered the highest quality of evidence based care.

Well the most important part of this whole story is the Physician who has to examine the patient and make the judgement whether the protocol is correct or needs to be modified in terms of medications, investigations or final disposition.

It’s not that simple and it’s wrong to assume that a protocol covers all. In a chest pain protocol the physician still has to rule out a Pneumothorax or Aortic Dissection. In sepsis the physician still has to decide the gravity and clinical condition of the patient and locate the source.

What if there is a Nausea Vomiting Protocol and the patient comes as DKA , I can remember multiple times that patient has come with nausea vomiting sugars of 1000 and his EKG shows an Acute MI but patient was being worked up on lines of Nausea and Vomiting.

I can tell you multiple incidents when patient came with symptoms saying that they had facial weakness and hemiplegia which resolved and was started on TIA protocol and I walk in and do a stroke scale and find the patient to have visual deficits and then change it to Stroke Alert Stat CT and TPA. Not every TIA goes for Stat CT with radiologist read in 10 minutes.

The point I am making is that Doctors are the ones whose knowledge will help the protocols to function optimality. 

Protocols have their downside too.

Developing protocols is cumbersome and time consuming and involves multiple departments, individual specialty guidelines, and operational rules and by-laws of the hospitals. There are times when the protocols finally see the light of the day and scientific evidence changes and again the protocols have to be modified.

These standardized rules have a downside at academic emergency departments. Post Graduate Students tend to just implement protocols without knowing each and every step in the protocol. They need to learn and understand the logic.

I am cautious to support these new era of “Short to the Point Lecture Format” which is immensely misleading and disastrous if one does not know the logic behind every point.

That is the very reason Boards in Emergency Medicine across the  world have a written as well as an oral component and only a handful of specialties in have both exams with majority only conducting and certifying based on MCQ Written Tests.

Emergency Medicine is a branch of Challenge and Opportunity.  

Emergency Physicians will never have patients to be followed as Primary Physician, They may not be great surgeons but they are surely doctors whose difference is visible and that too immediately.
The actions we take and the reactions to the actions is what saves the patients or doesn’t.

With responsibilities of MAKE OR BREAK on our shoulders, surrounded by an Era of Accountability to self and your patients and trenched in systems with egos, protocols, patient safety and quality, having the up to date knowledge becomes more crucial than ever.

On the other hand Teaching correct knowledge and practicing as per current algorithms is very important in our specialty.

We may have the best tools, we may have the most up to date rules but in hands of a fool there is no value to any tool or any rule because a fool is a fool regardless…..

Solution is .......cure the foolishness…read, learn, practice and improvise with a deep understanding of the scientific subject matter. 

We are dealing with lives and not some product manufacturing industry!